A Closer Look at Maternal Health in the U.S. and HHS Region VII

Introduction

Maternal health care plays an essential role in positive outcomes for both mothers and babies. Research suggests that there are several factors contributing to poor maternal health outcomes nationally, including a complex medical system, health insurance gaps, systemic racism and discrimination, and economic and geographical disparities. These factors have contributed to maternal mortality rates above the Healthy People 2030 target in Kansas and its Health and Human Services (HHS) Region VII neighbors, Missouri, Nebraska and Iowa.

Maternal health challenges have been discussed across Region VII, making it a priority topic for communities in the heartland. The Kansas Health Institute (KHI) conducted four listening sessions in 2024. Access to maternal health services was one of the key challenges for communities, especially among rural, Black, and Somali immigrant and refugee populations.

Disparities for these populations are reflected in national maternal mortality data. Maternal mortality rates are one indicator of maternal health that can offer insight into quality of care and outcomes before, during and after pregnancy. The U.S. maternal mortality rate decreased to 18.6 deaths per 100,000 live births in 2023, down from 22.3 in 2022. However, racial, ethnic and geographic disparities persist. In 2023, non-Hispanic Black mothers experienced the highest group rate of maternal mortality (50.3), more than double the U.S. overall rate. In 2021, the latest data available by geography, mothers in rural (non-metropolitan) areas also experienced a higher rate of maternal mortality (42.9) compared to mothers in metropolitan areas (31.3) and the U.S. (32.9).

These rates are higher than the Healthy People 2030 target rate for reducing maternal mortality, 15.7 deaths per 100,000 live births. The Region VII maternal mortality rates by state are higher than the national goal, as shown in Figure 1. Region VII state health departments have focused on addressing maternal health challenges, as shown in reports from: Kansas Department of Health and Environment, Missouri Department of Health and Senior Services, Nebraska Department of Health and Human Services, and Iowa Department of Health and Human Services. Region VII states also have extended Medicaid postpartum coverage for up to one year after birth.

Figure 1. Maternal Mortality Rates in Region VII and the U.S., 2018–2022

Note: Target is based on Healthy People 2030 goal. The maternal mortality rates are not age-adjusted. Maternal mortality data can vary widely between states and should be interpreted carefully. In many states, when there are small numbers of these tragedies, producing reliable statistics and rates is difficult. Five years of data are used to increase reliability. Differences in how states track and report maternal deaths — such as variations in technology and verification procedures — can lead to under- or overcounting. These inconsistencies make it difficult to compare states accurately.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, Maternal Mortality Rates State Data, 2018–2022.

This issue brief examines the distinct challenges faced by rural, Black, and Somali immigrant and refugee women when accessing maternal health care services. The brief also outlines various strategies that can deliver cross-cutting benefits to improve maternal health outcomes. These strategies can help support state and local policymakers, public health agencies, health care providers, health systems, community-based organizations, foundations and coalitions working to address maternal health outcomes gaps.

Barriers to Accessing Maternal Care for Rural, Black, and Somali Immigrant and Refugee Populations

There are distinct challenges for rural, Black, and Somali immigrant and refugee women who are pregnant, birthing and postpartum, but some strategies for addressing challenges could have cross-cutting benefits. As shown in Figure 2, health insurance gaps, inadequate coverage, difficulty navigating the health system and financial hardships were barriers to accessing maternal health services.

Figure 2. Barriers to Maternal Health by Population Group

Note: This figure includes common themes from a literature review of 22 national and 12 local studies, a total of 34 articles. Two of the articles focused on Somali immigrant and refugee populations.

Source: Kansas Health Institute literature review and analysis.

For rural communities, the closure of labor and delivery units experienced nationally is one of the biggest challenges related to maternal health care access. These closures — often due to financial challenges, staffing shortages and declining birth rates — have left many areas without hospital-based obstetric services. In counties not adjacent to urban areas, this loss has been linked to more out-of-hospital births, births in hospitals without obstetric services and reduced prenatal care. A report by Karen Weis and Alex Alsup released by the University of Kansas School of Nursing in May 2025 showed that the closure or pausing of facilities offering prenatal or labor and delivery services has caused an increasing number of women to travel up to 60 miles for care.

Across the U.S., research suggests that Black women experience the added burden of systemic racism. One study found that Black women waited 46 percent longer for emergency department care related to pregnancy concerns compared to White women. Delays in emergency care can result in increased morbidity and mortality. Structural factors also influence maternal health outcomes. A study found that Black women living in segregated neighborhoods faced compounded stress from discrimination and limited access to health care, which could affect mental health and lead to adverse outcomes. Mental health is another area of concern. One study found that Black women with low incomes who reported experiencing depression and anxiety when screened reported experiencing it throughout pregnancy and the postpartum period, as compared to Hispanic women with low incomes, who reported experienced depression and anxiety in the first trimester, with symptoms that declined over time.

For Somali immigrant and refugee populations, a strong preference for female providers due to religious and cultural reasons is a factor influencing access to health care, especially when it comes to women’s health needs. In addition to the medical team, it is important that interpreters translating sensitive information are also women. Research indicates that in Somali immigrant and refugee populations, mental health concerns, such as anxiety and depression, are not openly discussed because of stigma. Members of the Somali immigrant and refugee community may experience mental health challenges due to trauma experienced abroad (e.g., war, violence, forced migration, refugee camp experiences and separation from loved ones) and challenges experienced in the U.S. (e.g., literacy, education, employment and legal status).

Overall Strategies for Improving Maternal Health Outcomes

Addressing gaps in maternal health requires a multifaceted approach that accounts for structural barriers, workforce limitations and the unique needs of rural, Black, and Somali immigrant and refugee populations.

For all three populations, community-engaged programs that offer social support, such as group prenatal care, doula services or familial support, and community health workers have been found to increase engagement (e.g., attendance of prenatal sessions) and improve outcomes in Region VII and across the U.S., especially for Black and Somali immigrant and refugee women. Rural communities also report increased engagement when programs are tailored to their specific needs.

For example, among Somali immigrants and refugees, community engagement and cultural awareness and adaptation of services improved access to care for Somali immigrant and refugee women in a midwestern city participating in a group prenatal care model program named Hooyo (“mother” in Somali) that uses the CenteringPregnancy program, adapted to the East African context. This group-based setting provided the women with ways to build community and to acquire new knowledge about their own health (e.g., tools for stress management). Social support has been shown to be effective in engaging women in maternal health care access, with 93 percent of 17 participants in the study preferring group-based prenatal care instead of individual care.

Expanding the maternal health workforce can address some of the barriers related to access
and improve outcomes. For example, community health workers and doulas serve as critical support resources for Black women and Somali immigrant and refugee women. Tailored approaches that respond to the needs of rural communities can help address geographic and cultural barriers to care. Further, investing in midwifery education and support programs can be effective in addressing access gaps, especially for rural communities across the U.S.

Increased access to health insurance is associated with increased access to maternal health care services and improved outcomes. Support services that assist Medicaid enrollees in understanding and navigating coverage and health resources (e.g., explanation of benefits, lists of available providers, nutrition assistance, transportation assistance) play a vital role in ensuring access to care across the prenatal and postpartum continuum. Medicaid expansion has contributed to reduced uninsurance rates overall, although disparities in access to maternal care remain. Nationally, Medicaid expansion has improved access to maternal health services, especially for women born in the U.S., though gaps remain for some immigrants due to not being eligible for benefits.

Removing barriers such as lack of transportation and child care also were important in accessing maternal health care services. For example, women participating in the Hooyo program suggested wanting more frequent sessions, available child care and for the program to continue postpartum instead of ending after birth. Further, telehealth services have the potential to reduce barriers and bridge the maternal health care access gaps.

Several of the strategies for increasing access and improving outcomes are population specific. For rural communities, strategies include increasing access to affordable and consistent broadband internet and expanding midwifery education and support programs.

For Black or African American communities, strengthening social support proved to be important, particularly familial and peer support. Delivering social support through the workforce, such as community health workers, has been important in continued engagement. Another strategy for increasing trust in maternal health care services is to address racial discrimination. Standardizing medical care practices to reduce variation in emergency department wait times, along with engaging people with lived experiences in qualitative studies, can help improve programs and services, address concerns and build trust. Another step forward is to assure cross-agency collaboration and data sharing capabilities between health systems so that women receive a continuum of care, as some clinical settings experience low resources for a robust data system.

For Somali immigrant and refugee populations, supporting gender preferences in provider selection is important for religious and cultural reasons. Women prefer female care teams. Further, addressing barriers related to literacy, health literacy, medical system navigation and language will improve access to health care services for mothers. Providing culturally tailored services has proven to be effective.

Conclusion

There are cross-cutting strategies for improving access to maternal health care for rural, Black, and Somali immigrant and refugee populations. A community-engaged approach to addressing barriers to maternal health care access, such as transportation, child care, language and health system navigation, along with an expanded maternal health workforce and increased access to health insurance, can lead to improved outcomes.

Further, understanding the needs of intersectional groups (e.g., rural Black populations) may provide additional information that can help address programmatic and practice gaps. Research could be enhanced with greater focus on understanding the differing needs of African immigrant communities as compared to African refugee communities.

Finally, a learning collaborative focused on Region VII could provide a platform for contributing and collaborating across the region to address maternal health care access and outcomes gaps.

The authors thank Kansas Birth Equity Network’s Sharla Smith, Ph.D., M.P.H., and Oluoma Obi, M.P.H., and four community members with lived experiences who provided feedback for clarity and community-centeredness, as well as several rural and Somali-American community members who also provided input and guidance. The authors also thank subject matter experts in HHS Region VII for providing input on maternal health activities in the various Region VII states. Additionally, the authors thank Tonia Wright, Hanan Ismail, R.N., B.S.N., Jessica Seberger and Jamin Johnson, Ed.D., C.H.E.S., C.P.H., who provided guidance as subject matter experts in maternal health. They thank Dr. Babalola Faseru, MB.Ch.B., M.P.H., C.P.H., SRNT Fellow, and Mariah Charans, Ph.D., who served as subject matter expert reviewers on this issue brief. Finally, the authors acknowledge the efforts of the Kansas Department of Health and Environment, Missouri Department of Health and Senior Services, Nebraska Department of Health and Human Services, Iowa Department of Health and Human Services and their state and local partners for addressing maternal health outcomes in Region VII.

Valerie Emerson contributed to this work when she served as an intern at the Kansas Health Institute from August 2024 through May 2025.

Insert: Populations Are Not Mutually Exclusive

While the experiences of rural, Black, and Somali immigrant and refugee populations are discussed separately, it is important to note that these populations are not mutually exclusive. There are people who have experiences in multiple communities. For example, there are Black or Somali immigrant and refugee populations within rural communities who experience several challenges and barriers to accessing health care. A reference list of the 34 articles, including 22 focused on national studies and 12 on studies in a limited geographic area, was used to identify barriers and strategies for improving maternal health outcomes for rural, Black, and Somali immigrant and refugee populations. The Somali immigrant and refugee population within these two studies may not be representative of the Somali population across the U.S. and their experiences may be different from African immigrants and refugees from the other 53 African countries. The review considered implications for Region VII, but the findings were not regionally specific, unless noted.